When to discontinue insulin drip in Hyperosmolar Hyperglycemic State (HHS) patients

From the Guidelines

Discontinuation of insulin drip in patients with Hyperosmolar Hyperglycemic State (HHS) can be considered when the patient's blood glucose level has decreased to less than 200 mg/dL and the anion gap has normalized, as well as when there is resolution of acidosis and hemodynamic stability 1.

Key Considerations

• Typically, this occurs after 4-6 hours of insulin therapy with a dose of 0.1 units/kg/hour of regular insulin, such as Novolin or Humulin 1.
• Stable glucose measurements for at least 4–6 h consecutively, normal anion gap, and resolution of acidosis in diabetic ketoacidosis are essential factors to consider when transitioning patients from continuous insulin infusion to subcutaneous insulin 1.
• Once the insulin drip is discontinued, patients can be transitioned to subcutaneous insulin therapy, such as glargine (e.g., Lantus) 0.2-0.5 units/kg once daily, and aspart (e.g., Novolog) or lispro (e.g., Humalog) 0.1-0.2 units/kg before meals.

Transitioning to Subcutaneous Insulin

• An estimate of the combined basal and nutritional subcutaneous insulin requirements can be derived from the average amount of insulin infused during the 12 h before transition 1.
• The proportion of basal insulin and prandial insulin depends on the type of insulin to be used and the nutritional status of the patient 1.
• Careful monitoring of potassium concentrations is recommended, as hypokalaemia is common during treatment of hyperglycaemic crises 1.

From the Research

Discontinuation of Insulin Drip in HHS Patients

• The decision to discontinue insulin drip in Hyperosmolar Hyperglycemic State (HHS) patients is based on several factors, including blood glucose levels and the patient's overall clinical condition 2.
• According to a study published in the American Family Physician, insulin should be given as an initial bolus of 0.15 U per kg intravenously, followed by a drip of 0.1 U per kg per hour until the blood glucose level falls to between 250 and 300 mg per dL 2.
• Another study published in The Journal of Clinical Endocrinology and Metabolism found that the rate of plasma glucose decline in HHS patients after hydration and insulin administration was 80 +/- 7 mg/dl X h 3.
• A more recent study published in Critical Care Medicine found that moderate-intensity insulin therapy was associated with reduced length of stay in critically ill patients with diabetic ketoacidosis and HHS 4.
• The study suggested that insulin therapy should be designed to mitigate glycemic variability and hypoglycemia, rather than rapidly normalizing blood glucose levels 4.
• In terms of specific guidelines for discontinuing insulin drip, one study published in The Journal of Emergency Medicine recommended that treatment involves fluid resuscitation and correction of electrolyte abnormalities, and that patients should be monitored closely to avoid overcorrection of osmolality, sodium, and other electrolytes 5.

Key Considerations

• Blood glucose levels: Insulin drip should be continued until blood glucose levels fall to between 250 and 300 mg per dL 2.
• Glycemic variability: Insulin therapy should be designed to mitigate glycemic variability and hypoglycemia 4.
• Electrolyte abnormalities: Patients should be monitored closely to avoid overcorrection of osmolality, sodium, and other electrolytes 5.
• Clinical condition: The decision to discontinue insulin drip should be based on the patient's overall clinical condition, including their level of consciousness, vital signs, and other laboratory values 2, 5.